NUR2513/NUR 2513 Exam 1 V2 | Maternal-
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is calculating the expected date of birth (EDB) for a client whose last menstrual
period (LMP) began on June 15th. Using Naegele’s rule, which date should the nurse provide?
A. March 8th
B. April 22nd
C. March 15th
D. March 22nd
Correct Answer: D
Rationale: Naegele’s rule is a standard method used to estimate the delivery date based on
the first day of the last menstrual period. By adding seven days to the first day of the LMP
and then subtracting three months, the nurse can calculate the expected date of birth. This
calculation assumes a standard 28-day menstrual cycle and is a foundational assessment in
prenatal nursing.
2. A pregnant client reports feeling the fetus move for the first time. The nurse should
document this subjective finding as which type of sign of pregnancy?
A. Positive sign
B. Probable sign
,C. Diagnostic sign
D. Presumptive sign
Correct Answer: D
Rationale: Quickening, or the mother’s perception of fetal movement, is considered a
presumptive sign of pregnancy because it is subjective and could be caused by other factors
like gas. Presumptive signs are those that the client experiences and reports directly to the
healthcare provider. In contrast, probable signs are objective findings by the examiner, and
positive signs are definitive proofs of a fetus.
3. The nurse is assessing a client at 28 weeks of gestation who presents with a blood pressure
of 152/94 mmHg and 2+ proteinuria. Which condition is the client most likely experiencing?
A. Preeclampsia
B. Chronic hypertension
C. Gestational hypertension
D. Eclampsia
Correct Answer: A
Rationale: Preeclampsia is characterized by the onset of hypertension and proteinuria
after 20 weeks of gestation in a previously normotensive woman. The presence of protein
in the urine distinguishes preeclampsia from simple gestational hypertension. Eclampsia
would involve the same symptoms plus the occurrence of grand mal seizures.
,4. A client in labor is receiving an oxytocin infusion. The nurse notes fetal heart rate
decelerations that begin after the peak of a contraction and return to baseline only after the
contraction has ended. What is the priority nursing action?
A. Increase the oxytocin infusion rate
B. Discontinue the oxytocin infusion
C. Place the client in a supine position
D. Perform a vaginal examination
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a sign of fetal
distress and decreased oxygenation. The first and most critical action is to stop the
oxytocin infusion to decrease uterine activity and improve placental blood flow. Additional
interventions include repositioning the client to her side and administering oxygen via non-
rebreather mask.
5. A nurse is caring for a newborn immediately after birth. Which action should the nurse
take to prevent heat loss through evaporation?
A. Place the infant on a pre-warmed scale
B. Move the crib away from windows and air vents
C. Dry the infant thoroughly with warm blankets
D. Place the infant in skin-to-skin contact with the mother
, Correct Answer: C
Rationale: Evaporation occurs when moisture on the skin is converted to vapor, drawing
heat away from the newborn’s body. Drying the infant immediately after birth is the most
effective way to minimize this specific type of heat loss. Other methods like using warm
blankets and a cap further support thermoregulation by preventing convection and
radiation losses.
6. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which finding should the nurse report as a sign of magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Blood pressure of 140/90 mmHg
C. Increased urinary output
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: Magnesium sulfate acts as a central nervous system depressant, and toxicity can
lead to respiratory depression, defined as less than 12 breaths per minute. Another key
sign of toxicity is the loss of deep tendon reflexes, not hyperactive ones. The nurse must
monitor the client closely and have calcium gluconate available as the antidote.
7. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
Child Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is calculating the expected date of birth (EDB) for a client whose last menstrual
period (LMP) began on June 15th. Using Naegele’s rule, which date should the nurse provide?
A. March 8th
B. April 22nd
C. March 15th
D. March 22nd
Correct Answer: D
Rationale: Naegele’s rule is a standard method used to estimate the delivery date based on
the first day of the last menstrual period. By adding seven days to the first day of the LMP
and then subtracting three months, the nurse can calculate the expected date of birth. This
calculation assumes a standard 28-day menstrual cycle and is a foundational assessment in
prenatal nursing.
2. A pregnant client reports feeling the fetus move for the first time. The nurse should
document this subjective finding as which type of sign of pregnancy?
A. Positive sign
B. Probable sign
,C. Diagnostic sign
D. Presumptive sign
Correct Answer: D
Rationale: Quickening, or the mother’s perception of fetal movement, is considered a
presumptive sign of pregnancy because it is subjective and could be caused by other factors
like gas. Presumptive signs are those that the client experiences and reports directly to the
healthcare provider. In contrast, probable signs are objective findings by the examiner, and
positive signs are definitive proofs of a fetus.
3. The nurse is assessing a client at 28 weeks of gestation who presents with a blood pressure
of 152/94 mmHg and 2+ proteinuria. Which condition is the client most likely experiencing?
A. Preeclampsia
B. Chronic hypertension
C. Gestational hypertension
D. Eclampsia
Correct Answer: A
Rationale: Preeclampsia is characterized by the onset of hypertension and proteinuria
after 20 weeks of gestation in a previously normotensive woman. The presence of protein
in the urine distinguishes preeclampsia from simple gestational hypertension. Eclampsia
would involve the same symptoms plus the occurrence of grand mal seizures.
,4. A client in labor is receiving an oxytocin infusion. The nurse notes fetal heart rate
decelerations that begin after the peak of a contraction and return to baseline only after the
contraction has ended. What is the priority nursing action?
A. Increase the oxytocin infusion rate
B. Discontinue the oxytocin infusion
C. Place the client in a supine position
D. Perform a vaginal examination
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency, which is a sign of fetal
distress and decreased oxygenation. The first and most critical action is to stop the
oxytocin infusion to decrease uterine activity and improve placental blood flow. Additional
interventions include repositioning the client to her side and administering oxygen via non-
rebreather mask.
5. A nurse is caring for a newborn immediately after birth. Which action should the nurse
take to prevent heat loss through evaporation?
A. Place the infant on a pre-warmed scale
B. Move the crib away from windows and air vents
C. Dry the infant thoroughly with warm blankets
D. Place the infant in skin-to-skin contact with the mother
, Correct Answer: C
Rationale: Evaporation occurs when moisture on the skin is converted to vapor, drawing
heat away from the newborn’s body. Drying the infant immediately after birth is the most
effective way to minimize this specific type of heat loss. Other methods like using warm
blankets and a cap further support thermoregulation by preventing convection and
radiation losses.
6. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which finding should the nurse report as a sign of magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Blood pressure of 140/90 mmHg
C. Increased urinary output
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: Magnesium sulfate acts as a central nervous system depressant, and toxicity can
lead to respiratory depression, defined as less than 12 breaths per minute. Another key
sign of toxicity is the loss of deep tendon reflexes, not hyperactive ones. The nurse must
monitor the client closely and have calcium gluconate available as the antidote.
7. A client at 34 weeks of gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
